Question Answered step-by-step Admitting DiagnosisPathophysiology of medical diagnosis (APA format; 2 pages)History: to include history of present illness, personal, and social historyRelevant data (history)-5 pointsPhysical: include vital signs and exam (will need to put what symptoms would you see/hear)Nursing Care Plan:Assessment with Subjective/ObjectiveNursing Diagnosis (need 2) Goals (need 3)InterventionsEvaluationMedications: (at least 4 medications)Includes: Indications, Action (mode of action), Route, Onset, Peak, Duration, Contraindication, Adverse Reactions/Side Effects (major ones only), Interactions, and patient/family teaching Please answer the previous questions for the following scenario:This is prior to CovidJorge Reyes 48-year-old male who was born in Jalisco, Mexico, moved to West Sacramento when he was 5 years old with his family, He attended grade school and middle school in West Sacramento and transfer to Sac High to play football. He then attended Junior College at Sac City College, then went on to the police academy. He now works as a highway patrol man on nights in the route 5 and 99 sector. He has a wife and three children ages 2, 4, and 6, all boys with only the 6 year old going to school, Mom is a stay at home mom who recently has started to babysit two infants for a friend four days a week. This new job is adding to their income. Jorge tries to get home in time for the dinner meal with his family if he is in the area. His days off are Monday and Tuesday. They are catholic and the family attends Mass each week and he attends when he is able. He and his wife try to go out once a week and play softball or basketball with a group of their friends. In high school, he was on the football team and also played some baseball. Mrs. Reyes’ mother comes to watch the children the night they got out but the children mostly attend the ball games with their parents.Family history: father, age 70 has hypertension and on medication for the past 5 years and is well controlled, Mother has diabetes type 2 on medication (weight 150 height 5′) and her blood sugars are poorly controlled and she says she is “trying” but loves to eat rice and beans, sister is 30 no current health problems except obesity. Sister has two children ages 4 and 6 who are friends with Jorge’s children. They all live within 5 miles of each other. Mr. Reyes’s family moved back to Mexico and come to visit once a year for a month. (This sometimes adds a strain on his marriage as his parents think his wife should be working to help with the income and then their son would not have to work so hard)He comes into your ER because he has problems with his asthma. He has not had prior problems since high school but now is wheezing, short of breath with any effort like walking fast or climbing stairs. When he was small, he remembers going to the hospital because he could not breathe but does not remember if he stayed the night or what treatment he had. Currently. he has a headache, shaking chills, sneezing and nasal congestion with green exudate and headache over his sinus area (right side) He is also nauseated and has vomited with the coughing. The sputum he brings up is about a tablespoon and it is thick and grayish. He began with body aches this am. Which is making it hard for him to go to work. He was off the whole weekend and spent most of the time in bed. Did take some over the counter medication, Claritin D, and Robitussin which did not seem to help with the nasal congestion or headache. No one else in the home has the same symptoms. He did not sleep well the last 2 nights due to the cough and some wheezing. Does not have an inhaler at this time, but remembers he used one when he was young. No one else is sick at home.Today, he noticed that he felt chest tightness and some discomfort in his left arm. He thought this was from playing ball this past week-end. If he sits down the pain is less, returns as soon as he does any lifting or moving rapidly. Some sweating with any activity the past two days.As far as his past medical history he has been overweight for the past 5 years, has had bronchitis in 2015 given antibiotics and was well in a few day. Prior to that he was a smoker for 10 years but quit in 2015, smoking about a pack a day (10 pack years pk/yr) Occasionally has a beer or two at night especially when they play softball and holidays.He does not take any regular medication except an occasionalAdvil for discomfort after he plays ball,You note in the chart that he has not had his flu shot, pneumonia vaccine or any health care for the past 2 years even though he has health insurance.Vital signs: T: 103.6, P: 98 R: 26, BP 148/88, 02 stat is 95 % on room air (flocculates between 94% and 96%)Physical: pale, sweaty skin, says he cannot hear well out of his ears and has cloudy green nasal exudates, enlarged turbinate’s, there is no rash on chest, lungs coarse breath sounds with expiratory wheezes throughout his lung fields Tactile fremitus on lower back has increased vibrations. Heart irregular rhythm no murmurs, abdomen bowel sounds heard WNL some tenderness to palpation over his liver. He has a slight headache when he bends over to tie his shoe. He is coughing every once in a while as you are taking the history. The coughing has begun to hurt his chest. There is now a change with latest sputum and it has a slight streak of blood in it as well as green in color, thick which is the main reason he is here today.Lab results: Chest x-ray show an infiltrate in the right lower lobeCBC: WBC is 15,000 with 70% neutrophils 1% monocytes 20% lymphocytesUA is negative except for positive ketonesThe culture of sputum and Basic Metabolic Panel is still pendingRapid strep is negative for Beta hemolytic strep02stats are 95% on room air EKG shows normal sinus rhythmDiagnosis: PneumoniaPlan: Augmentin 875 mg every 12 hours for 10 daysFlovent MDI 2 puffs every 12 hoursAlbuterol MDI 2 puffs every 4-6 hours as needed for wheezing and to be used prior to FloventBreathing treatment was given prior to patient leaving theER with Xopenex with relief of coughing and wheezingIncrease fluids and rest, off work for an additional 48 hoursTo come to be rechecked prior to return to work at hisPrimary Care ProvidedGave work excuse for 48 hoursTo return to ER or RTC if not having chest pain or shortness of breathIn future plan: PPDPatient education for diet and exerciseUp to date on ImmunizationsPatient and wife discussion about familyMarriage counselingHealth evaluation: lab, x ray, immunizations Health Science Science Nursing NR 224 Share QuestionEmailCopy link Comments (0)
Question Answered step-by-step Admitting DiagnosisPathophysiology of medical diagnosis (APA format; 2 pages)History: to include history of present illness, personal, and social historyRelevant data (history)-5 pointsPhysical: include vital signs and exam (will need to put what symptoms would you see/hear)Nursing Care Plan:Assessment with Subjective/ObjectiveNursing Diagnosis (need 2) Goals (need 3)InterventionsEvaluationMedications: (at least 4 medications)Includes: Indications, Action (mode of action), Route, Onset, Peak, Duration, Contraindication, Adverse Reactions/Side Effects (major ones only), Interactions, and patient/family teaching Please answer the previous questions for the following scenario:This is prior to CovidJorge Reyes 48-year-old male who was born in Jalisco, Mexico, moved to West Sacramento when he was 5 years old with his family, He attended grade school and middle school in West Sacramento and transfer to Sac High to play football. He then attended Junior College at Sac City College, then went on to the police academy. He now works as a highway patrol man on nights in the route 5 and 99 sector. He has a wife and three children ages 2, 4, and 6, all boys with only the 6 year old going to school, Mom is a stay at home mom who recently has started to babysit two infants for a friend four days a week. This new job is adding to their income. Jorge tries to get home in time for the dinner meal with his family if he is in the area. His days off are Monday and Tuesday. They are catholic and the family attends Mass each week and he attends when he is able. He and his wife try to go out once a week and play softball or basketball with a group of their friends. In high school, he was on the football team and also played some baseball. Mrs. Reyes’ mother comes to watch the children the night they got out but the children mostly attend the ball games with their parents.Family history: father, age 70 has hypertension and on medication for the past 5 years and is well controlled, Mother has diabetes type 2 on medication (weight 150 height 5′) and her blood sugars are poorly controlled and she says she is “trying” but loves to eat rice and beans, sister is 30 no current health problems except obesity. Sister has two children ages 4 and 6 who are friends with Jorge’s children. They all live within 5 miles of each other. Mr. Reyes’s family moved back to Mexico and come to visit once a year for a month. (This sometimes adds a strain on his marriage as his parents think his wife should be working to help with the income and then their son would not have to work so hard)He comes into your ER because he has problems with his asthma. He has not had prior problems since high school but now is wheezing, short of breath with any effort like walking fast or climbing stairs. When he was small, he remembers going to the hospital because he could not breathe but does not remember if he stayed the night or what treatment he had. Currently. he has a headache, shaking chills, sneezing and nasal congestion with green exudate and headache over his sinus area (right side) He is also nauseated and has vomited with the coughing. The sputum he brings up is about a tablespoon and it is thick and grayish. He began with body aches this am. Which is making it hard for him to go to work. He was off the whole weekend and spent most of the time in bed. Did take some over the counter medication, Claritin D, and Robitussin which did not seem to help with the nasal congestion or headache. No one else in the home has the same symptoms. He did not sleep well the last 2 nights due to the cough and some wheezing. Does not have an inhaler at this time, but remembers he used one when he was young. No one else is sick at home.Today, he noticed that he felt chest tightness and some discomfort in his left arm. He thought this was from playing ball this past week-end. If he sits down the pain is less, returns as soon as he does any lifting or moving rapidly. Some sweating with any activity the past two days.As far as his past medical history he has been overweight for the past 5 years, has had bronchitis in 2015 given antibiotics and was well in a few day. Prior to that he was a smoker for 10 years but quit in 2015, smoking about a pack a day (10 pack years pk/yr) Occasionally has a beer or two at night especially when they play softball and holidays.He does not take any regular medication except an occasionalAdvil for discomfort after he plays ball,You note in the chart that he has not had his flu shot, pneumonia vaccine or any health care for the past 2 years even though he has health insurance.Vital signs: T: 103.6, P: 98 R: 26, BP 148/88, 02 stat is 95 % on room air (flocculates between 94% and 96%)Physical: pale, sweaty skin, says he cannot hear well out of his ears and has cloudy green nasal exudates, enlarged turbinate’s, there is no rash on chest, lungs coarse breath sounds with expiratory wheezes throughout his lung fields Tactile fremitus on lower back has increased vibrations. Heart irregular rhythm no murmurs, abdomen bowel sounds heard WNL some tenderness to palpation over his liver. He has a slight headache when he bends over to tie his shoe. He is coughing every once in a while as you are taking the history. The coughing has begun to hurt his chest. There is now a change with latest sputum and it has a slight streak of blood in it as well as green in color, thick which is the main reason he is here today.Lab results: Chest x-ray show an infiltrate in the right lower lobeCBC: WBC is 15,000 with 70% neutrophils 1% monocytes 20% lymphocytesUA is negative except for positive ketonesThe culture of sputum and Basic Metabolic Panel is still pendingRapid strep is negative for Beta hemolytic strep02stats are 95% on room air EKG shows normal sinus rhythmDiagnosis: PneumoniaPlan: Augmentin 875 mg every 12 hours for 10 daysFlovent MDI 2 puffs every 12 hoursAlbuterol MDI 2 puffs every 4-6 hours as needed for wheezing and to be used prior to FloventBreathing treatment was given prior to patient leaving theER with Xopenex with relief of coughing and wheezingIncrease fluids and rest, off work for an additional 48 hoursTo come to be rechecked prior to return to work at hisPrimary Care ProvidedGave work excuse for 48 hoursTo return to ER or RTC if not having chest pain or shortness of breathIn future plan: PPDPatient education for diet and exerciseUp to date on ImmunizationsPatient and wife discussion about familyMarriage counselingHealth evaluation: lab, x ray, immunizations Health Science Science Nursing NR 224 Share QuestionEmailCopy link Comments (0)
